Provided by Barbara K. Tomar, ACEP’s Federal Affairs Director
The Medicare Access and CHIP Reauthorization Act (MACRA) Final Regulation was released Oct. 14. This rule – now designated by CMS as the “Quality Payment Program”- describes requirements for physicians to participate in the Merit-based Incentive Payment System (MIPS) and/or the Advanced Alternative Payment Models (Advanced APMs). Both begin January 1, 2017.
Former ACEP President Dr. Mike Gerardi appointed an APM Task Force that is developing some models that we hope will be reviewed and approved by CMS over the next year. Work of the Task Force was overseen this past year by Immediate Past President Dr. Jay Kaplan and current ACEP President Dr. Becky Parker has pledged to continue to support Task Force efforts.
It’s important to note that since few emergency physician groups have ever participated in various CMS bundled payment models/ACOs, etc. in the past, we expect most of the members to participate in MIPS for the next year or so.
We were pleasantly surprised in our early review of the 2,200-page rule, that CMS responded to ACEP’s comments on the timing and scope of some of the new programs.
Merit-based Incentive Payment System (MIPS):
- Reduces timeframe for reporting. Instead of reporting quality measures (much like PQRS) for a full calendar year starting in January, members can report for as little as 90 days of their choosing and avoid the 4% penalty in 2019. (Similar to PQRS, there will be a 2-year lag between data reporting imposition of bonus/penalty.)
- Doctors can report MIPS as individuals or through their groups. However, physicians must elect one or the other for all MIPS categories.
- Quality measures reporting reduced from 9 to 6. Either 6 measures or a specialty measure set can be selected, 1 of which must be an outcome measure; if no outcome measures are available, a high priority measure.
- Reporting thresholds reduced from 90% of patients (or 80% for claims reporting) to 50% in 2017.
- Encourages the use of QCDRs and electronic sources through preferential scoring.
- Increases quality percent of composite performance score: 60 percent of the composite performance score will be based on the quality performance category in 2017, due to the (requested) reduction of the cost performance category weight to zero next year. CMS was going to weight ‘resource use’ at 10% – a nearly impossible measure for EM due to current cost attribution methodology.
- CMS working on patient condition and patient relationship codes to improve future cost attribution. (ACEP’s recent comment letter to CMS noted that none of the patient relationship codes fit EM practice so we will continue to work with CMS to change this).
- (Clinical) Improvement Activities reporting burden reduced. Highly-weighted activities (20 points) reduced from 3 to 2 and medium-weighted activities or some combination of both need to equal 40 points. (Use of QCDR is highly weighted).
- Allows 90-day reporting, also.
- Advancing Care Information (previously known as Meaningful Use) reporting reduced.
- EM has been exempt from reporting on EHR measures and may continue to be in spite of the burden placed by the hospitals.
- Also reduced to 90-day reporting for 2017-2018
Advanced Alternative Payment Models (APM):
- Reduces amount of losses that APMs must bear. CMS used the term “more than nominal risk” in the draft and proposed that qualified APMs pay of to 4% of Medicare spending. The final rule is based on physician/APM revenue which would be at risk for 5% of revenue losses instead.
- Expanded the definition to include practitioners other than physicians so that models can address quality and costs of non-physician services.
Physician-focused payment model Technical Advisory Committee (PTAC):
Note: This brief description of PTAC is included as background as no changes to its role were made in the final rule.
- MACRA created the PTAC (of outside experts) to assist physician groups who are creating APMs, providing a first line review of proposals to determine whether such proposed models meet the criteria established by the Secretary of HHS for PFPMs and offering some technical assistance. Based on its findings, PTAC can make recommendations to CMS as to whether the model should be refined, further studied, tested or implemented, but CMS makes the final decision through its own application process.
September 25, 2016
The following statement is from ACEP President Jay A. Kaplan, MD, FACEP:
As an organization that represents more 37,000 emergency physicians around the country and the world, the American College of Emergency Physicians applauds our members who stand on the front lines of the violence that occurs in our country every day. Some of that violence makes the nightly news. Sadly, the majority does not.
Our members treat victims and perpetrators, abusers and the abused, law enforcement officers, paramedics, firefighters, prisoners, and death row inmates. We treat the destitute and the wealthy, men and women, citizens and foreigners, and Presidents and pariahs.
ACEP members do it without regard to race, religion, sexual orientation, creed, nationality, socioeconomic class or the ability to pay. We daily see in our emergency departments victims of violence and abuse who no one ever hears about and who we continue to worry about; sometimes that violence is directed against us, just as it is against the law enforcement officers with whom we work.
We are saddened by recent events that that seem to dominate the news every day, as well as by the stories we experience recurrently which do not make the news. We join the call for an honest dialogue about how to turn the tide on the lack of humanity and compassion that leads to the violence we witness outside and inside our departments every hour of every day. Until the day it ends, our members will be on duty around the country to heal the wounds that afflict the victims and our country.
The American College of Emergency Physicians (ACEP) is proud to announce the launching of the new, High Threat Emergency Casualty Care Task Force (HTECCTF). The task force will be under the leadership of Co-Chairs Gina Piazza, DO, FACEP and David Callaway, MD, FACEP with Debra Perina, MD, FACEP, ACEP Board Liaison
Since 2000, there have been over 200 active shooter incidents, resulting in over 1216 victims with over 548 deaths. This tally does not include gang violence, bombings, non- gun related mass assaults or other gun- related violence. In 2011, the multi-disciplinary Committee for Tactical Emergency Casualty Care, was formed to address this emerging threat. In 2014, the first Hartford Consensus document was published that further articulated a critical gap in prehospital preparedness. Later that year, ACEP participated in a multi-specialty working group funded by the Department of Homeland Security and coordinated by the National Association of State EMS Officials (NASEMSO). This working group produced a white paper that identified the lack of high threat prehospital response guidelines as one of the top five critical gaps in domestic EMS preparedness.
In the fall of 2015, The White House issued a call to action to address the challenges of reducing morbidity and mortality from active shooter incidents and terrorist attacks and to expedite the translation of combat lessons learned to the civilian setting.
ACEP is in a position to serve as an effective coordinating body across professional organizations that represent EMS, trauma care, and emergency medical services.
The purpose of this two-year initiative is to create a comprehensive strategy to address trauma care from point of injury through definitive care in high threat emergencies. The Task Force will be involved in building and coordinating external partnerships regarding high threat emergency casualty care.
The goals of the task force include:
- Leverage member expertise and leadership to create policies and procedures that reduce morbidity and mortality in high threat emergencies.
- Strengthen the national voice in the policy discussions surrounding response to active shooter incidents and active violent incidents.
- Serve as a resource for high threat emergency care and work with current ACEP representatives to other professional organizations.
- Leverage international networks to create national and international standards for high threat emergency medical care.
- Serve as an advisory body on topics of high threat emergency casualty care including but not limited to:
- Creation of all-hazard response guidelines for high threat care
- Translation of military emergency medicine and out-of-hospital (EMS) lessons learned to the civilian setting
- Promote the integrated response to dynamic mass casualty incidents such as rolling disasters, acts of terrorism and active shooter incidents.
- Support the provision of psychological support to victims of and responders to dynamic mass casualty incidents
- Promote the integration of non-medical first responders into community preparedness plans
The task force roster has been completed and was chosen from a pool of over 80 extremely qualified individual applicants as well as stakeholder organizations and federal agencies representing a vast knowledge base and expertise applicable to this very important and timely work. The membership includes:
- American Academy of Emergency Medicine (AAEM)
- American College of Emergency Physicians (ACEP)
- American College of Surgeons-Committee on Trauma (ACS-COT)
- The Office of the Assistant Secretary for Preparedness and Response (ASPR)
- Committee for Tactical Emergency Casualty Care (CTECC)
- International Association of Chiefs of Police (IACP)
- International Association of Fire Chiefs (IAFC)
- Interagency Board (IAB)
- National Association of EMS Physicians (NAEMSP)
- National Association of State EMS Officials (NASEMSO)
- ACEP representatives from the Committees of Disaster Preparedness and Response, Emergency Medical Services and Pediatric Emergency Medicine and the Sections of Event Medicine, EMS Prehospital Care, Tactical Medicine, Disaster Medicine, International, Pediatric Emergency Medicine and Wilderness Medicine.
- United States Department of Health and Human Services, Emergency Medical Services for Children (EMS-C)
- United States Department of Homeland Security (DHS)
The task force work has begun, including the first face-to-face meeting at ACEP16 in the Mandalay Bay Convention Center in Las Vegas, Nevada on October 18, 2016 from 7:00-9:00 AM, in the South Seas Ballroom A.
For further information the ACEP Staff contacts for the task force are:
Patrick Elmes, EMT/P
EMS and Disaster Preparedness Department
American College of Emergency Physicians
1125 Executive Circle
Irving, Texas 75038-2522
(972) 550-0911 Ext. 3262
Deanna Harper, EMT/I
EMS and Disaster Preparedness Department
American College of Emergency Physicians
1125 Executive Circle
Irving, Texas 75038-2522
(972) 550-0911 Ext. 3313
As President-Elect, Dr. Becky Parker has two visions for ACEP – establishing emergency medicine as the nucleus of a new acute care continuum and fostering diversity and inclusion within the specialty.
In her speech to the ACEP Council last October, Dr. Parker stated, “Studies clearly demonstrate that more diverse organizations are stronger and more successful. We will increase our wellness, longevity, and grow our desperately needed workforce. Inclusivity sends a clear message: we take care of our own.”
ACEP has hired Tracy Brown, a diversity consultant, to help facilitate a Diversity Summit, slated for Thursday, April 14 at the ACEP national office. Ms. Brown is an experienced consultant who has worked with organizations nationwide on diversity and inclusion strategy. ACEP is excited about engaging her as a partner in this process.
The primary objectives for the Summit include:
- Provide environmental data that’s important to the specialty of emergency medicine
- Create a safe space to share stories; create dialogue, new ideas, and awareness
- Capture results and identify areas of focus that will influence a 2-3 year Diversity and Inclusion Strategic Plan for ACEP
“Emergency physicians have a unique perspective in leading the charge of diversity and inclusion. When I’m standing above a patient in their hour of need, the rest of world fades away. All presuppositions and notions vanish. Nothing else matters,” said Dr. Parker. “As physicians, we chose emergency medicine because we love taking take care of everyone. Now it’s time to take care of ourselves.”
Summit participants represent the following categories: age, gender, religion, race/color, and LGBT. These individuals represent the designated communities and also bring special knowledge, research, publication, and/or leadership in the topic and within emergency medicine.
Invited Participants include:
- Steven H. Bowman, MD, FACEP
- Kerryann B. Broderick, BSN, MD, FACEP
- N. Adam Brown, MD, MBA, FACEP
- Craig Savoy Brummer, MD, FACEP
- Wesley A. Curry, MD, FACEP
- Vidya Eswaran (student)
- Katherine “Kate” L. Heilpern, MD, FACEP
- Sanford “Sandy” H. Herman, MD, FACEP
- Sheryl Heron, MD, MPH, FACEP
- Robert S. Hockberger, MD, FACEP
- Muhammad N. Husainy, DO, FACEP
- Tiffany D. Jackson, MD (resident)
- Jay A. Kaplan, MD, FACEP
- Dara Kass, MD, FACEP
- Kevin Klauer, DO, EJD, FACEP
- Linda L. Lawrence, MD, FACEP
- Michael “Mike” Lozano, MD, FACEP
- Abhi Mehrotra, MD, FACEP
- Aasim I. Padela, MD, MSc, FACEP
- Rebecca B. Parker, MD, FACEP
- Sanjay Pattani, MD, FACEP
- Hala Sabry, DO
- Java Tunson, MD (resident)
Right on time…. Apologies for delay everyone, holidays put a spell on the audio equipment, it seems. Audio is now posted!
-Imaging foreign bodies: Everything you’ve ever wanted to know
-Chest CT occult traumatic injury findings, a study
-Low risk chest pain scoring systems: how do they stack up in one cohort?
-ED a Fib management and quality of life: FINALLY, a study that asks the right question!!!
-30 day mortality after A fib management in the ED: deriving a risk score
And lots lots more. Check it out, January coming soon….
Report from the Section Council on Emergency Medicine: Highlights of the AMA Interim Meeting, Nov 2015, Atlanta, GA
515 of 540 Delegates sat for debate on the Monday opening of the House of Delegates (HOD). We were fresh off a Capitol Club luncheon starring a PBS anchor and Fox News reporter about the current state of Presidential Campaigning. Fascinating but impossible to predict seems the result as all known rules don’t seem to apply.
We typically have a 30-minute opening session of the HOD on Sunday morning. Instead, 90 minutes later the House recessed to reference committees after a lengthy exercise in parliamentary procedure referable to a new rule on “A motion to table” which is not debatable. The AMA recently changed its parliamentary resource from Sturgis to the American Institute of Parliamentarians Standard Code of Parliamentary Procedure. With the addition of this rule, it was used to prevent debate on a subject that the HOD did not seem to want to spend time discussing, namely issues related to Planned Parenthood. Arguments ensued about denial of opportunity for a minority to be heard. The House voted about 350 to 109 to table. Part of this plurality was due to the issue and part probably due to angst against the physician who brought the issue, having brought similar issues to the HOD repetitively in the past.
A special reference committee on the Modernized Code of Medical Ethics heard testimony on the latest Council on Ethical and Judicial Affairs (CEJA) effort to modernize the code. The code was again referred back for further work based on numerous objections. An example is the Code does not allow a physician to participate in assisted suicide. However many states have laws that allow physicians to do so. California law apparently stipulates that the state law will trump the AMA Code of Ethics. But many states do not have this protection.
Unanimous testimony was offered in support of the medical student resolution to remove disincentives and study the use of incentives to increase the national organ donor pool. Misery and disability due to lack of organs is evidenced every day in our practices. The HOD voted first to support a study on use of incentives, including valuable consideration, second to eliminate disincentives and third to remove legal barriers to research investigating the use of incentives.
The HOD voted to support seeking over the counter approval from the FDA for Naloxone and to study ways to expand the access and use of naloxone to prevent opioid-related overdose deaths.
There were resolutions that touched on balance billing and network adequacy as it relates to emergency services. One was reaffirmed as previous AMA policy endorsing fair payment for emergency care. Another was adopted directing the AMA to advocate that health plans be required to document to regulators that they meet requisite standards of network adequacy, including for hospital-based physician specialties at in-network facilities and supporting that insurers pay out-of-network physicians fairly and equitably for emergency and out-of-network bills in a hospital.
There were again multiple resolutions regarding MOC which were referred to the Board for ongoing action reflecting the productive dialogue between ABMS and the AMA/Council on Medical Education. GME was again highlighted as an urgent need for action to expand GME positions to better match the expansion of medical school graduates.
Medical students proposed multiple resolutions regarding the need to address wellness throughout the medical education/practice environment.
As usual, several educational sessions were also held at the AMA. The AMA website summarizes several of those sessions, including:
- “5 things every modern medical practice needs”
- “Physicians reaffirm commitment to stop insurance mergers”
- “Attend to EHRs so we can attend to patients, physicians say”
- “CDC panel shares solutions to combat antibiotic resistance”
- “New program helps develop the skill set every physician needs”
- “Get published using these 5 writing and research tips”
Highlights of the opening session were two. First was a presentation by President Steve Stack to Cal Chaney, an executive recognition award for his outstanding contributions to the AMA and ACEP during his many years as staff of the Section Council on Emergency Medicine. Second was of course an outstanding address by our AMA President, Steve Stack, a speech interrupted numerous times by thunderous applause. The Board of Trustees members are uniformly complimentary and appreciative of Steve’s service on the Board and his performance as President. We are justly proud of him and having an emergency physician as President of the AMA. You can see a synopsis of his speech and hear it at the following link:
ACEP and EMRA were also proud to host a reception for medical students attending the Interim Meeting to mingle and discuss careers in emergency medicine with the medical students. In addition to ACEP’s five delegates and five alternate delegates, the EM footprint in the HOD continues to grow and flourish. 21 emergency physicians serve as HOD delegates or alternate delegates for their state societies. Several others serve in key positions on various councils and sections. Among those emergency physicians, other interested physicians, medical students and ACEP staff attending one or both of the Section Council on Emergency Medicine meetings were:
Nancy J. Auer, MD, FACEP
Mark Bair, MD
Michael D. Bishop, MD, FACEP
Brooks F. Bock, MD, FACEP
Michael L. Carius, MD, FACEP
Ted Christopher, MD
John Corker, MD
Shamie Das, MD, MPH, MBA
Erick Eiting, MD
Stephen K. Epstein, MD, MPP, FACEP
Hilary Fairbrother, MD, MPH
Catherine Ferguson, MD
Gary Figge, MD
Diana Fite, MD, FACEP
Wayne Hardwick, MD
Marilyn Heine, MD, FACEP
David Hexter, MD, FACEP
Rebecca Hierholzer MD
Amy Ho, MD
Tiffany Jackson, MD
Jay Kaplan, MD, FACEP
Gary Katz, MD
Seth M. Kelly
Marc Mendelsohn, MD
John C. Moorhead, MD, MS, FACEP
Joshua B. Moskovitz, MD, MPH, FACEP
Richard Nelson, MD
Reid Orth, MD, PhD, MPH
Rebecca B Parker, MD, FACEP
Craig Price, CAE
Alexander M. Rosenau, DO, CPE, FACEP
Matthew Rudy, MD
Sarah Selby, DO
Michael J. Sexton, MD, FACEP
Steven Stack, MD, FACEP
Richard L. Stennes, MD, MBA, FACEP
Ellana Stinson, MD
Arlo Weltge, MD
Jennifer Wiler, MD, MBA, FACEP
Dean Wilkerson, JD, MBA, CAE
Joseph P. Wood, MD, JD, FACEP, FAAEM
Carlos Zapata, MD
Posted! Highlights include:
-Identifying barriers to detecting child abuse
-Cost advantages of the ‘Low Risk Ankle Rule’
-Crowding in the ED, associations with outcomes after discharge
-Jet injector for venipuncture pain in kids
-Everything you wanted to know about how the ACA affects EM
-Vent management 101 – back to basics
And way more, as always.
Reach out any time, we’d love to hear from you,
Once again, the podcast/audio is full of good stuff.
-ED prescriptions for warfarin and long term use: remarkable adherence benefits?
-Nitrates in aortic stenosis — another myth busted?
-Review of d-dimer for detecting aortic dissection
-Steroids in anaphylaxis: not helping?
-Cricothyrotomy in the recently deceased
-Caring better for LGBT patients
And more, more, more.
Let us know what you think, email any time, and enjoy ACEP 2015!
September Annals Audio is posted here, check it out:
-Ketamine v morphine for pain
-Is droperidol safe for agitation… the unsurprising answer
-Opiates in the ED: 1) the patient perspective, 2) ED prescribing patterns
-Contrast-induced kidney injury, and one year outcomes
-Ebola triage and decision aid, transport of Ebola patients, and ED Ebola processes
and, as always, much much more.
Until next time, email any time at firstname.lastname@example.org,
The August episode of the Annals Audio/Podcast is now available here. Highlights include:
-Color coding pediatric resuscitation syringes: a new (i.e. better) way
-Oral contrast in peds abdominal trauma: worthwhile or worthless?
-Antibiotics only for peds appendicitis: the literature
-Vital signs at handoff — “Forgot to mention: he’s hypotensive…”
-H Pylori testing in the ED
-Tackling smoking in the ED, a RCT: it worked
-QT prolongation in antipsychotic overdose: less common than we thought?
Check it out and email anytime at email@example.com!